HARM REDUCTION AS A GOAL - HOW TO GET THERE?

There are four general harm reduction goals: (1) prevent persistent, irreversible or severe harms after a harm has emerged; (2) prevent harmful consequence by early intervention; (3) reduce the likelihood that a harmful situation arises; and (4) maintain conditions that are not harmful or hazardous. Health practitioners and investigators work to reduce harm across the continuum from a premature or bad death, through disease and disability, to optimal well-being. Total harm faced by a population can, in general, be reduced by reducing the total amount of harm (which is achieved by reducing exposure or sensitivity), or by reducing the total impact of harm (achieved by increasing capacity to cope or reducing cumulative effects) (Figure 6.1) (Stephen et al., 2018).

A taxonomy of harm reduction actions. This classification links general actions to harm reduction goals. Harm reduction programs require multi-level actions targeting more than one goal

FIGURE 6.1 A taxonomy of harm reduction actions. This classification links general actions to harm reduction goals. Harm reduction programs require multi-level actions targeting more than one goal.

Goal 1: Intervene in a Harmful Situation to Prevent Persistent, Irreversible, or Severe Harms

In this scenario, harms have occurred. Recovery, mitigation, and remediation are key words in this circumstance. The goal is to lessen the impact of an ongoing harm, minimize the duration of the effects, and ensure it does not lead to irreversible harm. This is the realm of treatment and rehabilitation in clinical medicine. The health promotion practitioner may not be involved in delivering clinical services, but he or she could ensure equitable access to effective and appropriate health services to mitigate inequities in access to care. Removing socio-cultural, organizational, economic, geographic, and gender-related barriers to health care underpins equitable access to care (Evans et al., 2013). Socio-economic impediments can also deter people from accessing animal health services. For example, poverty limited farmer’s access to preventive veterinary services in the Nepalese case described earlier. Subsidized or free veterinary services in developing countries or remote areas are examples of harm reduction for livestock development.

A challenging question, whether for people, animals, or ecosystems, is what to restore or recover, and how close to historical states should we aim? The question may seem easier for people or individual animals where we can strive to recover and individual back to its former state or to the norms of form and function expected by society. It becomes more challenging when thinking of ecosystems.

Take for example the 2010 oil spill in the Gulf of Mexico. Millions of barrels of oil that leaked into the ocean were met with millions of barrels of chemicals intended to disperse the oil. Political leaders vowed to restore the Gulf back to how it was before the spill. Unfortunately, the state of the Gulf was not pristine before the spill. The region had endured centuries of natural and technologically hazardous events. The impacts of the spill were immense, but so too were the challenges of pollution, habitat loss, overfishing, and climate change before the spill. Similar challenges can be found in recovering endangered species. What happens, for example, when two endangered species are engaged in a predator- prey relationship, such as sea otters and abalone in the United States, or lions and giraffes in Africa, or reindeer and wolves in Europe? Managers need to assess the acceptability and feasibility of controlling predator pressures to the extent that prey species can recover without further increasing the vulnerability of the predator.

Trade-offs in management strategies will affect restoration or recovery goals (e.g. see Box 6.1). These often involve trade-offs between values (e.g. ecological vs economic), preferences (e.g. saving charismatic species rather than cryptic unattractive species), or current versus future generations (e.g. carbon taxes). Because socio-ecological systems provide multiple health services which influence each other, decision-makers need to consider the system-wide synergies or trade-offs between ecosystem services, well-being components, and values being affected by decisions made. Ecologic, economic, and systems dynamic models can be used with participatory methods to systematically examine trade-offs in recovery and rehabilitation efforts.

BOX 6.1 CASE STUDY: FINDING WIN-WIN SOLUTIONS WHEN RECOVERY AND REHABILITATION GOALS CONFLICT — A CASE OF INVASIVE SPECIES ACTION VERSUS ENDANGERED SPECIES PROTECTION

Freshwater mussels are some of the most endangered groups of animals in North America. The Rocky Mountain ridged mussel (Gonidea angulata) is a bivalve species whose Canadian range is limited to the Okanagan Valley, British Columbia. Its habitat is being encroached upon by the invasive Eurasian watermilfoil (Myriophyllum spicatum). Milfoil control is a local priority due its impact on the recreational and real estate value of lakeshore properties. Protecting the mussels was believed to require curtailment of milfoil control in portions of the lake, a solution unpalatable to local businesses and politicians. Mapping the overlaps in distributions of these two species helps identify adaptive management strategies by proposing evidence-based buffer zones and/or tailoring milfoil control activities to site-specific mussel- milfoil overlaps (Figure 6.2). Milfoil control can help protect habitat quality for the mussels and, therefore, could be reframed as a shared conservation and invasive species goal, rather than a competitive goal.

Measuring the spatial overlap of Rocky Mountain ridge mussels and Eurasian watermilfoil in Okanagan Lake

FIGURE 6.2 Measuring the spatial overlap of Rocky Mountain ridge mussels and Eurasian watermilfoil in Okanagan Lake, British Columbia, Canada, to gather evidence to create win-win solutions for endangered species and invasive species management. (Image credit Joy Wade.)

Goal 2: Intervene Early in a Harmful Situation BEFORE THE OUTCOMES CAUSE NOTABLE DAMAGE

Early warning is the key phrase for this scenario. The goal is to act quickly to limit the extent of harms that could occur if the harmful situation was left unattended. Actions try to prevent the early signs of harms turning into disease or loss of function. Screening tests play a major role for this form of harm reduction in clinical medicine. Tests or examinations seek sub-clinical signs of disease that inspire interventions that prevent clinical effects, like blood pressure testing to screen for pre-clinical cardiovascular disease. To be effective, this form of harm reduction needs to generate signals that inspire people to act. Confidence is needed in the predictive value of early warning signals. Despite some challenges in linking early warning signs in clinical medicine with the certainty of a harmful outcome, tremendous gains in combatting individual and community harms from many diseases have been made through health screening. Routine recording of blood pressure, cholesterol, urine sugars, and cervical cytology, for example, have become standard part of annual physical exams as part of the battle against diabetes, cardiovascular disease, and cancer, respectively.

The pace of environmental and social changes is creating a greater need for screening for upcoming threats and identifying the most vulnerable population in advance of harms. Confidence in taking preventive steps requires access to the right information fast enough from a trusted source. The use of animal or environmental signals as early warning for human diseases underlies the founding premise of One Health. Much has been written about the use of animal and ecological indicators as early warning of pandemics and emerging diseases. Less has been written about how well these indicators motivate people to act in a way that reduces harms. The frequency with which animal and ecological early warning signs are suggestive of human disease risk exist without an associated human disease outbreak far outnumber the few occasions when a risk to humans does emerge. Despite billions of dollars spent globally to predict the next emerging infectious disease, we continue to be surprised by emerging threats, such as the coronavirus pandemics (COVID-19) of 2020 and the emergence of Zika virus in the Americas before that. It is no surprise that repeated proclamations of disease outbreak early warning without concomitant impacts creates future warning fatigue.

There are methods to predict emerging diseases, but so far, they act as “the art of the possible” rather than predictive tools to direct specific risk management actions in specific locations and times. Significant knowledge gaps for even the most studied threats along with a view of causation disconnected from social and ecological context reduces the likelihood that we will be able to predict surprising harms with accuracy or regularity in the foreseeable future. The rate of health surprises is expected to accelerate in the Anthropocene and to grow beyond infectious diseases to include changes in contaminant exposure, catastrophic events like wildfire and floods, and shifts in access to natural resources that underpin economic and cultural needs. While we may not predict the next surprise, we still need early warning systems to help anticipate vulnerable situations in order to prioritize limited resources.

Surprises arise when there is a gap between what you expect and what occurs. Our expectations can be restricted when we limit what we listen to (so we are unre- ceptive or insensitive to warning signals outside of our usual scope of practice); who we listen to (such as when priorities and overcrowded agendas discourage collaborations that extent beyond immediate interests), and what we believe (power dynamics, too much information, and wishful thinking can lead to failure to recognize and act on very early warning signals) (Stephen, 2019). Five warning scenarios and associated foci for early warning are presented in Table 6.1. Accessing, integrating, and applying information from a socio-ecological system perspective is needed for early warning of changes at the human-animal-environment junction. But, more importantly, early warning signals need to be adapted to the community being warned and often need to be sought from more than one agency. Surprise anticipation can be enhanced by improving awareness of changes in

TABLE 6.1

Five Early Warning Scenarios and Their Focus for Early Warning

Scenario

Situation

Focus

Risk management

Health managers are fully aware of the nature of the hazard and the vulnerability of the community or ecosystem

Document how a known hazard is changing in distribution or abundance and inform local risk perception to modify protective and preventive actions accordingly

Coping assessment

There is uncertainty about how a community or ecosystem can cope with known hazards

Track changes to determinants of health that influence sensitivity to harms and coping capacity

Hazard detection and monitoring

Variation in community, individual, or system vulnerability is primarily driven by differences in exposure to known hazards

Provide reliable signals of the distribution and abundance of known hazards and information on the likelihood of exposure by examining changes in social or ecological interactions

Signals of effect

A suspected hazard is present in the environment but there is insufficient evidence of effect to warrant risk reduction actions, or there are newly introduced or previously unknown agents, the effects of which are unknown

Link the presence of the agent/hazard with a biological effect to inform recognition of a risk and help prioritize risks requiring further assessment or management

Mixed strategies

The characteristics of community or system vulnerability are largely unknown and effects of hazards unanticipated

A mixed strategy combing attributes of the four preceding scenarios is warranted

Source: Adapted from Stephen and Duncan. 2017.

distributions of and exposure to hazards and/or variations in population vulnerability or resilience to shocks (Figure 6.3) (Stephen et al., 2015).

Goal 3: Reduce the Likelihood That a Risky Situation Will Initiate Harmful Outcomes

This form of harm reduction focuses on reducing the likelihood that a harm will occur. Prevention is the keyword. Actions are promoted in advance of a measurable harm. Understanding the risks inherent in a situation allows you to prioritize and target actions to reduce risk as well as to examine any offsets between the risks and benefits of that situation.

Risk factors are any attribute, agent, or situation that affects the likelihood of harm. Risk factors are not diagnostic. They give a sense of the likelihood of

The relationship between the type of surprising circumstance one could encounter and general responses to prepare for the next surprise. (Adapted from Stephen et al.. 2015.)

FIGURE 6.3 The relationship between the type of surprising circumstance one could encounter and general responses to prepare for the next surprise. (Adapted from Stephen et al.. 2015.)

something occurring in populations like the ones from which risk estimates have been derived. Risk factors can be categorized in many ways. There are modifiable and non-modifiable risk factors. There are environmental, social, behavioural, and biological risk factors. There are individual, population, and community risk factors. Care must be taken in making inferences about the impacts of risk factors measured at one level (like an individual) on another level (like a community). Additional care needs to be taken in extrapolating the impacts of a risk factor in one species (like a cow) to another (like a deer). Risk factor analysis is contextual.

Another distinction is the difference between perceived risk and a measured risk. Measured risks are the outcome of epidemiological studies that systematically compare a study group with a control group that presents the same characteristics of the study group, except for the risk factor being studied. Perceived risk refers to individuals’ “instinctive and intuitive reactions to danger” (Slovic and Peters, 2006). Both types of risk are real, and both are prone to error. Measured risks are influenced by the limitations of study design, challenges in finding adequate control groups, and problems in generalizing how multifactorial systems work in one context compared to another. The issue of finding enough true controls becomes more challenging as we move from individuals to communities to ecosystems because as systems become more complex, finding identical compositions and relationships becomes more difficult. Perceived risks are influenced by culture, personal experience, psychological state, and social norms. They can, therefore, vary significantly within and between communities. Mobilizing society and individuals to act preventatively needs one to be attentive to perceived risks.

Instead of concentrating solely on risk factors in isolation, greater attention is now paid to interacting risks. For example, obesity in pets has been linked to genetic predisposition, reproductive management, and dietary/exercise management (Bland et al„ 2009). Obesity in humans has been linked to trade liberalization, economic growth and rapid urbanization that change environments, diets, and lifestyles in ways that promote positive energy balance (Malik et al., 2013). Interventions focused on changing the diet and exercise behaviour of individuals without attending to the condition leading to obesogenic conditions have had little impact on the obesity epidemic (Dehghan et al., 2005). Harm reduction focused on preventing obesity requires a variety of interventions targeting attitudes, lifestyles, and environments of people or pet owners to create the circumstances that keep normal-weight patients from becoming obese. Comprehensive prevention planning is important because of the multiple, complex individual, community and societal and ecological factors that not only drive the origins of obesity- related harms but also influence the ability and willingness to act in advance of harms.

Pandemic planning is an example where planners need not only consider risk factors that influence the likelihood of a pandemic but also those that influence motivations to act in advance of disease outbreak (Stephen. 2019). Being aware of and understanding a risk does not inevitably lead to risk avoidance. Personal experience, risk perception, trust in authorities, and exposure to false alarms, all affect willingness to act. A study of Chinese chicken farmers found that farmer personal attributes (gender, age, education, risk perception), farm production variables (animal density, feed conversion ratios, chicken weight gain), and societal variables (access to services, availability of subsidies), all affected farmer biosecurity decisions to reduce avian influenza risks (Huang et al., 2016). The innumerable reports of people violating recommendations or requirements for social distancing during the 2020 coronavirus (COVID-19) pandemic further demonstrated that acceptance of logical risk reduction recommendations is not universal, even when people are provided the same facts in the same media. Knowledge of the presence of a pathogen may be helpful but is often insufficient to motivate risk reduction actions. Risk management at this stage requires attention to facts, knowledge, and beliefs. Chapter 9 provides details on motivating health promoting and harm reduction actions.

Goal 4: Create an Environment Where the Underlying Conditions Leading to Harmful and Risky Situations Are Unlikely to Occur

Resilience, thriving, and flourishing are three words associated with this form of harm reduction. The goal at this stage is to equip people with the knowledge, resources, and circumstances that allow them to make choices that build health promoting capacities in themselves, their communities, other species, or ecosystems (e.g. see Box 6.2). The focus is on avoiding, removing, or mitigating pressures that lead to unhealthy conditions or environments that can lead to harmful situations. This can be achieved either by compulsion (such as laws or penalties) or voluntarily (by incentives or by finding win-win situations producing healthy co-benefits).

Social and economic structures along with personal choices and behaviours can determine decisions and actions that promote reciprocal care of human, animals, and environmental health. Addressing these factors can be a challenging yet effective investment in health. For example, clean indoor air laws, tobacco taxes, and reducing sodium from the food supply can have profound impacts on settings and decisions that affect cardiovascular health for a large segment of the human population (Weintraub et al.. 2011). Modern dairy herd health has developed into a transdisciplinary approach, combining sociology, psychology, economics, behavioural science, and communication with classical veterinary disciplines to motivate farmers to make systems-wide decisions to protect animal health and productivity (Kristensen and Jakobsen, 2011). Ecosystem conservation without cultural considerations is not only insufficient but also risks unanticipated negative impacts to communities (Poe et al., 2014). Climate change adaptation is another proactive, health promoting form of harm reduction. It tries to create a sustainable future for all people and species through an integrated approach at all scales. It recognizes the limits of natural and human systems to adapt to climate change and advocates for a new future where people retain critical functions,

BOX 6.2 CASE STUDY: MATCHING EVOLVED NEEDS WITH LIVING CONDITIONS TO PROMOTE ANIMAL WELFARE AND CREATE COMMUNITY CONSERVATION AWARENESS

A new phenomenon of community-based, capture-hold-release aquariums is an example of the harm reduction in practice that is attentive to social, conservation, and animal welfare needs. These types of aquariums (Figure 6.4) have been growing in number in small coastal communities as ways to increase community connection to local marine environments by displaying local animals for shorter periods while avoiding negative perceptions about holding individual animals too long in captivity. They strive to have a low ecological footprint as well as promote awareness and activities to protect local marine environments through environmental health literacy and community-based action. However, their remoteness, facility design, and scale can sometimes prevent access to veterinary services and infrastructure that allow medical intervention typical of larger aquariums. They are, therefore, heavily dependent on creating the conditions that provide the captive animals access to the resources needed to stay healthy. While biosecurity and early triage of ill animals are instrumental health management tools, success is found by matching the species’ adapted capacities and the realities of its holding environment. This is done by the habitat design, species composition and density, animal collection and transportation protocols, regulating and monitoring public access, and feeding protocols using accessible local foods that all match the animals’ biology (Stephen et al., 2019b).

A giant Pacific octopus in acoastal community capture-hold-release aquarium

FIGURE 6.4 A giant Pacific octopus in acoastal community capture-hold-release aquarium.

resources, and opportunities that will allow health to continue. Strong and closely connected communities are better able to adapt to, withstand, or get out of harm’s way in a disaster, which in turn contributes to the future well-being of individuals and communities (Wulff et al„ 2015). Policies that decrease social inequities and improve social cohesion can minimize and offset the drivers of change (Bunch et al„ 2011). Working upstream in a One Health world means creating the social and ecological conditions that concurrently enable healthful situations for animals, society, and environments.

Health and environmental literacy are important in this realm of harm reduction due to the reliance on affecting people’s attitudes and behaviours. Health literacy supports individuals’ capacity to obtain, process, and understand information and services needed to make appropriate health decisions. Environmental literacy promotes awareness of and concern for the environment and provides the knowledge, skills, and motivations to work towards solutions of current problems and the prevention of new ones (McBride et al., 2013). Ecological health literacy promotes everyday practices that support the sustainability of both non-human and human communities. It integrates concepts from environmental literacy and health literacy to develop a range of skills and competencies that people need in order to seek out, comprehend, evaluate, and use information to make informed choices that improve quality of life and protect the environment (Finn and O’Fallon, 2017). Concurrently promoting actions to protect human, animal, and environmental health requires competencies not only in communicating complex science in an integrated and accessible manner but also in mobilizing information to communities and individuals that may have diverse risk perceptions and conflicting values. Chapter 9 describes in more detail some theory and methods to support people making healthy decisions for themselves or the animals or ecosystems they care for.

 
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